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Behavioral Health Quality Assurance & Improvement Manager, Prineville, OR

Lutheran Community Services NW


Prineville, OR

July 20, 2017

About Us:

Lutheran Community Services Northwest is a non-profit human services agency that improves the lives of people in over 30 communities throughout Washington, Oregon and Idaho. We provide a wide variety of services to adults, adolescents, children, families, schools and communities – including behavioral health & alcohol/drug programs, family & community services, child welfare, refugee & immigrant services, senior & disability services, and crime victim assistance. We are privileged to touch lives of all ages, cultures and faiths.

Our employees are service-based and mission driven individuals who take a holistic approach to patient care. We offer a unique opportunity to work in an innovative, collaborative, and supportive environment and are looking for like-minded individuals to join our interdisciplinary team.

About Prineville:

Nestled in Central Oregon’s River Canyon Country and close to Bend and Redmond, Prineville offers some of the best year-round outdoor adventures. Opportunities for paddling, hiking, cycling, golfing, skiing, snowboarding, and sledding abound. Prineville is home to numerous public parks - including Ochoco Creek and Rimrock Parks, natural wonders, scenic drives, and family-friendly events. Enjoy our eclectic restaurants and sales tax-free shopping.

The Role:

The Quality Assurance Manager evaluates clinical services for compliance with accreditation and/or certification standards; coordinates and/or assists in activities regarding the development and implementation of plans and time frames for correcting deficiencies involving these standards. The QA manager will assist with coordinating program activities to meet laws, regulations and funding directives with the Directors. The QA manager will develop and maintain tools/forms/systems for auditing charts to ensure timeliness and the best standards of care are present across clinical programming.

Job Duties:

Audits / Reviews:

Oversees all internal QA&I reviews
Ensures all programs and staff are appropriately reviewed and audited on a regular basis
Ensures appropriate feedback is given to the staff and managers about internal audit results
Works with external auditors / reviewers to ensure throughout the complete audit process from start to finish
Work with financial staff to develop and implement quality assurance processes as required and in compliance with all appropriate agency requirements
Ensure development and completion of all necessary Corrective Action Plans
Review and sign off on all clinical staff documentation for interns and trainees as required by licensing agencies. Documentation will be expected to be signed off within 48 hours of clinician completion.


Tracks all reporting requirements for each grant / contract
Works with the appropriate staff and managers to ensure completion of all reports prior to given deadlines
Ensures all reports are accurate, submitted on-time or early and actively provides feedback to appropriate stakeholders about all reports submitted, for the purpose of QI


Ensure adherence to all contracts and grants
Provide the necessary support to ensure all grants and contracts are renewed (this could include, but is not limited to, providing data, providing reports, tracking the renewal dates and working on the grants and contracts themselves)
Review new contracts and grants to provide recommendations about viability of program related to QA&I

Staff Training / Technical Assistance:

Coach, mentor, motivate and lead all staff in the quality processes
Provide training and TA to Managers and Directors
Ensure that team provides training and TA to staff
Use data gathered to develop training programs, education materials, tools, templates, handouts, etc.
Develop an effective training program to ensure compliance and continuous quality improvement

Program Management:

Interview, hire, train and supervise quality assurance staff and other staff as needed.
Provide oversight and support to team of QA&I staff members
Develop systems of tracking and monitoring metrics for each program as well as the district office as a whole
Work with appropriate stakeholders to develop and maintain the office’s QA&I Plan annually
Develops systems in which proactive audit, review, feedback and training occur to ensure compliance with required standards
Attends all appropriate QA&I meetings (internal and external)
Work with stakeholders to ensure all necessary and required policies, procedures and protocols are developed, implemented and trained on
Provide professional representation, as needed, for the Directors at meetings
Provide consultation and support to the Directors and Managers related to all things QA&I
Develop training plan for QA&I program staff
Develop annual quality budgets as applicable
Process all Incidents, Accidents and Grievances, ensuring that they are appropriately reviewed, resolved, signed-off on and reported (when appropriate, work with the Director of Organizational Excellence to ensure all incidents are completely resolved)
Oversee the development and implementation of consumer satisfaction surveys
Process and report on all surveys, address areas of concern

***May be assigned other tasks or duties reasonably related to their job responsibilities***

Minimum Required Education: Masters Degree
Minimum Experience: 2 Years
Minimum Field-of-Expertise: Current Oregon State License LMFT, LPC, LCSW. Must be licensed for a minimum of 2 years. Previous auditing experience with focus on quality assurance and improvement.

If you are interested in applying for this position, please submit your resume, cover letter, and salary expectations to recruiter@lcsnw.org.

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